F0689

D

Failure to Follow Two-Person Transfer Plan Resulting in Resident Skin Tears

Commack, New York Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and that adequate supervision and assistance were provided during transfers. The resident involved had muscle weakness, spinal stenosis, difficulty walking, and functional limitation in range of motion in one lower extremity. A Quarterly MDS documented moderate cognitive impairment with a BIMS score of 11 and indicated the resident was dependent on staff for sit-to-stand mobility, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers, requiring the assistance of two or more helpers. Occupational Therapy and Physical Therapy communication forms, the CNA Kardex for the month, and the comprehensive care plan all documented that the resident required two-person assistance for tub/shower and other transfers and used a wheelchair for mobility.

Facility policies titled “Activities of Daily Living” and “Safe Transfers and Movement of Residents” required CNAs to review the CNA Task List/Kardex and to transfer residents only in accordance with their current assessment and care plan, using the required level of staff assistance and appropriate devices. Despite these requirements, on the date of the incident, the assigned CNA took the resident alone to the shower room for a scheduled shower and did not request assistance from other staff. The CNA reported that they typically did not check a resident’s Kardex and acknowledged being aware that this resident required two-person assistance for transfers. In the shower room, the CNA instructed the resident to hold the grab bars and attempted to transfer the resident from the wheelchair to the shower chair without a second staff member.

During the first transfer attempt, the resident stood but was unable to turn, and the CNA seated the resident back in the wheelchair. The CNA then attempted the transfer again, this time grabbing the back of the resident’s pants and pivoting the resident from the wheelchair into the shower chair alone. After completing the transfer, the CNA observed that the resident was bleeding and brought the resident to the nursing station. Nursing staff assessed multiple skin tears: one on the top of the right hand, one on the left lateral hand, and one on the left shin. An Accident and Incident Report and an Investigative Summary concluded that the resident sustained these skin tears as a result of the CNA’s failure to follow the established plan of care requiring two-person assistance for all transfers. Interviews with nursing and rehabilitation leadership confirmed that a one-person transfer from the wheelchair to the shower chair was unsafe for this resident and that the transfer was not performed in accordance with the resident’s care plan and therapy instructions.

Interviews with nursing staff further established that the CNA did not seek help before attempting the transfer and did not perform a safe transfer as per the resident’s plan of care. The LPN on duty reported that the CNA brought the resident to the nursing station with impaired skin on the left hand and leg and stated that the injuries occurred during the shower. A registered nurse confirmed that the CNA admitted to transferring the resident alone despite the known requirement for two-person assistance. The Assistant Director of Nursing and the Chief Nursing Officer both stated that the resident’s plan of care required two-person assistance for transfers and that the CNA did not follow this plan, resulting in the resident’s multiple skin tears. The overall finding was that the facility did not ensure the resident’s environment remained as free of accident hazards as possible by failing to ensure staff adhered to the resident’s assessed transfer needs and care plan.